Episode 60.0 – Aggressive Resuscitation of Diabetic Ketoacidosis

DKA should be suspected in any patient with altered mental status and hyperglycemia. Get a VBG (ABG not necessary) to confirm the diagnosis.
Hypokalemia kills in DKA. Aggresively replete potassium and consider holding insulin, which drops serum potassium, until K is greater than 3.5
The insulin bolus isn’t necessary and appears to cause more episodes of hypokalemia. Just start insulin as an infusion at 0.14 units/kg
Be vigilant about cerebral edema. Any change or deterioration in mental status should prompt treatment and evaluation. Mannitol in the euvolemic, normotensive patient and 3% hypertonic saline in the hypotensive/hypovolemic patient
Finally, don’t forge to always hunt down the underlying cause of the DKA. Infection and non-compliance is the most common so liberally administer broad spectrum antibiotics if you’ve got even a hint of infection brewing

https://www.youtube.com/watch?v=P9sKk4JZmso

Additional Reading

LITFL: EBM Diabetic Ketoacidosis

Core EM: DKA

Core EM: Episode 13.0 – Diabetic Ketoacidosis: A Case

emDocs: Myths in DKA Management

REBEL EM: Is There Any Benefit to an Initial Insulin Bolus in Diabetic Ketoacidosis?

References

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Savage MW et al. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabet Med. 2011 May;28(5):508-15. PMID: 21255074

Villon A et al. Does bicarbonate therapy improve management of severe diabetic ketoacidosis? Crit Care Med 1999; 27: 2690-2693. PMID: 10628611